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Social Prescribing Impact Report April 2016 - March 2018

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Contents

Foreword Page 3

Social Prescribing: Wellbeing 4U in

Cardiff & The Vale of Glamorgan Page 5-9

Key Highlights April 2016 to March 2018 Page 10-15

Case Studies Page 18-19

Learning and Recommendations Page 20-22

Summary Page 23-25

Foreword

Demand for healthcare is increasing, compounded by an aging population, increased prevalence of chronic

health conditions and increased cost pressures. The NHS in Wales face many challenges with almost half

(48 per cent) of Welsh governments budget spent on health and social care. Wales has the highest rates of

long-term limiting illness in the UK and the number of people aged 65 and over is projected to increase by

50 per cent by 2037.

It is estimated that around 20% of patients consult their health care professional for what is primarily a

social problem. In 2015, the population of Cardiff and the Vale was 529,752; therefore an estimated

105,900 appointments could have been made for social welfare issues.

A large proportion of health outcomes, estimated at 70%, are a result of social and economic determinants

of health including employment, financial security, housing, diet and exercise, familial and social networks.

Patients choose to consult with their GP when they feel overwhelmed as they often don’t know where else

they can go for help. As the pressure on the NHS continues to grow, with the combination of funding

limitations, people living longer (and often not in good health), and increasing prevalence of long term

health conditions, it is becoming more important to focus our efforts on finding new effective ways to

prevent, treat and sustainably manage health.

Social Prescribing (SP) initiatives provide an asset based approach to addressing these challenges by

facilitating people and communities to come together for positive change, tapping into their skills,

knowledge, lived experiences and interests on issues they encounter in their everyday lives

Social Prescribing is part of the shift from traditional top-down models of care delivered in GP surgeries and

hospitals to a non-medical, more networked approach by placing the patient at the centre of their care,

promoting independence and personal responsibility. It helps de-medicalise health conditions and

represents a formal means of making links to locally accessible opportunities for patients enabling them to

act to resolve or better support their condition.

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Social Prescribing is about causes, not symptoms; treatment options start with the person, not the illness

or the condition. SP is based on a clear set of values about harnessing existing personal and community

assets to achieve wellbeing. It is about ‘additionality’; expanding the range of options available to both

patients and professionals, promoting new perspectives and driving innovation

In Wales, Social Prescribing (SP) is increasingly gaining traction. Discussions are being facilitated by the

National Professional Lead for Primary Care, the Future Generations Commissioner and many health

practitioners about utilising SP as one of the solutions to support better health and the ‘What Matters?’

principle underpinning the Social Services and Wellbeing Act 2014 and the Five Ways of Working contained

in the Wellbeing Future Generations Act 2015. This leads us towards the use of social prescribing as an

important feature of primary care.

A recent survey by Nesta identified that four out of five GPs think social prescriptions (alongside 2 medical

prescriptions) should be available from GP surgeries. Social prescribing is often not recognised as a health

intervention and as such services are usually focused on direct health outcomes. However, the growing

evidence base suggests there are a wider range of benefits of social prescribing beyond those directly

associated with health including:

Behavioural change and lifestyle improvement

Improvement of psychological and mental wellbeing

Community integration and reduction in social isolation & loneliness

Benefits to physical health

Social Prescribing provides a non-medical alternative and often complementary intervention to support a

person’s desire to increase their physical and mental wellbeing. It is widely acknowledged that people who

are better connected to their community and have a sense of purpose and belonging can achieve a

happier, healthier life.

Social Prescribing can alleviate some of the pressures currently experienced in primary and secondary care

which are struggling in the current climate. By facilitating the patients’ access to a whole range of 3rd

sector and local services there is much potential to nurture local social capital and catalyse health creating

communities that strengthen their ability to care for themselves and each other. The Low Commission

reported 15% of GP visits were for social welfare advice. 3

There are several models of Social Prescribing; two of the most recognised are the Bromley by Bow Centre

and Rotherham SP where these principles have been in action for many years with sound 4 5 outcomes

for both the patients and the health services.

While more robust, systematic evidence is needed, a recent review found social prescribing has been

shown to improve self-esteem, sense of control and empowerment, wellbeing, reduce anxiety and

depression and a reliance on primary and secondary care.

There are further economic benefits, Nesta’s People Powered Health programme suggests the cost of

managing patients with long-term conditions could be reduced by up to 20 per cent and the Rotherham

Social Prescribing Pilot estimates over five years a return of investment (ROI) of £3.38 for every £1

invested.

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Schemes are not always called Social Prescribing. Link worker schemes, wellbeing projects and many other

initiatives are underway in the UK. They are all based on the same principle of creating more resilient and

resourceful communities and assisting our overstretched health service.

1 The Marmot Review 2010 ‘Fair Society Healthy Lives’ 2 http://www.nesta.org.uk/news/social-prescriptions-should-be-avaiable-gp-surgeries-say-four-five-gps (November 2016) 3 The Low Commission; evidence review and mapping study 2015. http//www.lowcommission.or.uk/dyn/1435582011755/ASA-report_Web.pdf 4 Bromley by Bow http://www.bbbc.org.uk/bbbc-social-prescribing 5 Rotherham Voluntary Action www.varotherham.org.uk/social-prescribing-service/

Social Prescribing: Wellbeing 4U in Cardiff and the Vale of Glamorgan

The current model was commissioned by Cardiff and Vale University Health Board using funding from

Welsh Government. It commenced in April 2016 for an initial period of two years to be reviewed in April

2018.

Aim of the programme;

Wellbeing Coordinators were appointed to work at the interface between the GP, patient and community

to deliver public health prioritise, embed public heath principles and enhance the social model of care

through the use of existing community networks and experience of co-production. The Wellbeing

Coordinators work closely with the Cluster Community Directors within which they operate to pro-actively

take forward those elements of social prescribing that are embedded within the cluster plans; supporting

patients to access alternative services that could have a positive impact on their health and wellbeing.

The initiative is managed by the Thrive team who are part of United Welsh. United Welsh is a registered

social landlord operating under charitable rules. They work hard to support the most vulnerable people in

our society and have more supported housing beds than any other housing association in Wales. They

work with more than 30 different providers including the Wallich, Gwalia & Gofal to make sure people get

the help and support they need. They work with individuals of all ages who are homeless, those with

learning disabilities, young people leaving care, women fleeing domestic abuse, those recovering from

substance misuse and people with mental health problems. Their Community Investment teams immerse

themselves in the neighbourhoods where they work to support the community to live well.

The SP initiative operates across three primary care localities; working in areas defined as areas of social

and economic deprivation. A team of 8 (full and part time) Wellbeing Coordinators and a Health Coach

deliver the service in the following surgeries: -

Cardiff Vale of Glamorgan

Fairwater Health Centre Highlight Park Practice

Lansdown Surgery Court Road Surgery

Caerau Lane Surgery Hub, taking referrals from Waterfront Medical Centre

Westway’s Medical Centre Ravenscourt Surgery

Woodlands Medical Centre Westquay Medical Centre

Ely Bridge Surgery Practice of Health

Grange Medical Centre Hub, taking referrals from

Saltmeade Medical Centre

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Clare Road medical Centre

Corporation Road Surgery

Cardiff Bay & Grange Health Centre

At the outset of the initiative 6 surgeries were identified by the cluster leads as possible sites to locate the

Wellbeing 4U Coordinators and over the two-year period, through demonstrating the effectiveness of the

model, other surgeries came onboard.

Health Demography

Cardiff has the third highest proportion of the most deprived local areas out of all the local authorities

in Wales with 17.6% of people living in these areas 6

Within the Vale of Glamorgan, 14% of local areas are amongst the most deprived in Wales

In Cardiff, men living in the most deprived areas can expect to live, on average, 11 years less than

those in the higher socio-economic groups. The gap is even wider for healthy life expectancy with a gap

of 24 years for those living in the most deprived areas compared to those in the more affluent areas

For the Vale, the gap is 8 years and 21 years respectively

In the most deprived areas, 28.4% of children are either overweight or obese compared to 0.9% of

those living in the least deprived areas

The uptake of the flu vaccination is also lower in deprived areas

The number of prescribed medicines per head of population in Wales increased by a quarter

between 2005 and 2014

The increase in Type 2 Diabetes is predicted to rise from 4.32% in 2010 to 9.86% by 2030 7

Wales dispensed the highest number of prescription items per head of population - 25.9 compared to

21.9 in Northern Ireland, 20.2 in England and 19.1 in Scotland 8

Using demographic trends it is projected that obesity levels and the number of people eating less than

five portions of fruit and vegetables per day looks set to increase 1

The population is estimated to rise by 1% in the Vale and by 10% in Cardiff over the next 10

years

In the recent report ‘ Cardiff and The Vale of Glamorgan Populations Needs Assessment’ more than half

of respondent’s ( 55.3%) specified that they sought help and advice from their GP on social issues

The number of people with 2 or more chronic illnesses is increasing, and as people age they are more

likely to experience multiple conditions at the same time (‘multi-morbidity’). Unhealthy behaviours are

1 http://gov.wales/docs/statistics/2017/170505-future-trends-report-2017-en.pdf

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common in older people too, just as with the rest of the population. In particular there is concern over

significant numbers of older people who drink excessive alcohol.

6 Cardiff Council (2017) What Matters Key Indicators Overview of performance 2015 Diabetes UK, State of the Nation, Challenges for 2015 & Beyond report7 http://gov.wales/statistics-and-research/prescriptions-dispensed-community/?lang=en8

How the scheme works

GPs, other healthcare professionals and practice staff within the network of active surgeries refer patients

in need of support with issues affecting their physical and / or mental health and wellbeing. Referrals are

made using a standard form that is received in the Wellbeing Coordinator’s ‘in-tray’ in the surgery. Patients

can also self-refer.

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Patient Pathway

The Wellbeing Coordinator contacts the patient and invites them to a face-to-face session. The

coordinators use motivational interviewing techniques, coaching-based skills and the transtheoretical

model (also known as Stages of Change) of behavior change. This is an integrative theory of therapy that

assesses an individual’s readiness to act on a new healthier behavior, and provides strategies, or processes

of change to guide the individual. The person is supported to tell their whole story, identify and prioritise

key issues and challenges they may face and then support the person to make a decision on how to move

forward to resolve the situation or move towards a behaviour change. A Coordinator can work with a

patient from 1 to 6 sessions to support their needs.

Role of the Coordinator

The role of the coordinator is multi-layered and involves building relationships with community leaders

and voluntary and statutory services; providing face-to-face patient support; coaching and motivational

intervention; developing relationships with referrer communities; keeping abreast of the changes in

provision; managing relationships with health care professionals and administering the required

processes of the scheme effectively.

Role of the Health Coach

The implementation of a health coach evolved during the last quarter of the first years funding in

response to lag times in patient accessing services due to over demand and gaps in local provision.

Health coaching, which can also be referred to as wellness coaching, is a process that facilitates healthy,

sustainable behaviour change by challenging and supporting a client to identify their values, develop their

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gaols, and transform these goals into action. To support people in their journey, over time, four workshops

were developed in co-production with other third sector and local health authority:-

Community Practice Walking Groups; a group primarily for patients to join at their practice, once a week,

to promote walking and socialising, breaking down the barrier of isolation and encouraging exercise for

health and mental wellbeing

Confidence Building Groups; team members were trained by EPP Cymru to deliver a four-week course in

the community for patients who suffer from low self-esteem, isolation and poor mental health. Many of

these patients attend while waiting for their appointment with the PMHT. This intervention helps the

patient understand some tools and techniques they can utilise to manage their mental health

Foodwise in the Community. Trained by the UHB Dietetics team this 8-week course supports a patient’s

learning around healthy eating, identifying alternative food options, motivations surrounding good food

choices, overcoming challenges to improve nutrition, sustainable weight loss and building activity into

everyday life

Tier 0 Stress Control. Trained by Cardiff and The Vale Primary Mental Health Team this course is designed

to help people learn to control their stress or anxiety better.

Following on from a year of successful programs the Healthful Network was established, in response to

patients requests to have a forum to continue their learning and keep the connections they had made;

When a patient attends or completes one of the health coach courses they will gain access to a sustainable

support network to better enable them to maintain the positive changes they have made. They are invited

to engage with a closed Facebook page that includes other patients who are also working on positive

behavior changes. A monthly newsletter and educational emails will be sent to enhance learning. Patients

will also be invited to attend quarterly workshops designed to bring people together and give them regular

contact and opportunity to share experiences. This process and structure will provide continued support to

patients and create opportunities to build resilience.

Feedback to Referrers

Where requested, feedback is given monthly directly to the practice managers detailing the number of

referrals and action taken. Every three months, a quarterly report is produced which sums up the data

across the participating practices by locality.

From direct feedback, it is clear that health care professionals are under enormous time pressure and

social prescribing is one route to alleviate this pressure. It takes time for the referring community to

become fully aware of the benefits of social prescribing and a process of ongoing communication by the SP

provider is essential.

The Wellbeing Coordinators achieve this by attendance at the practice clinical meetings and presenting

updates at cluster meetings.

Key highlights from April 2016 - March 2018

1,749 referrals were made to the service (this includes the additional 252 referrals made by the South-

East Cluster for a project period of 6 months from Oct 2017 – March 2018. This project was funded directly

by the cluster)

84% of all referrals were for ‘Wellbeing’ broken down by Overall Wellbeing at 33.7% (both Physical

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& Social/economic) Mental Health at 28.7%, Social impact issues (housing, debt, relationship etc.) at

11.79%%and Physical health (nutrition, exercise etc.) at 9.44%

The remaining referrals were made up of harmful behaviours (substance misuse), support with education

on screening & immunisation and help for people attending their GP frequently where alternative

interventions could be a better solution

68% of patients that were referred went onto engage with the Wellbeing Coordinator

1,701 signposting and referrals were made to the specialist third sector organisations and local

voluntary community groups and educational establishments. 2 %, only 34 patients, were referred onto

other statutory services

A further 443 patients were directly targeted, by lists provided by the practices, to reach those patients

who would benefit from advice surrounding immunisations (namely adult Flu vaccination) and screening in

those hard to reach communities

An additional 156 people were engaged at various co-produced health events in Cardiff and the Vale

59% of respondents to a patient survey (returns 133) reported their wellbeing had improved after

engagement with the Wellbeing Coordinator

100% of respondents said the signposting and/or the support given was relevant and useful

96% said they would refer the service to a friend or family member in need of support

The implementation of the Health Coach and Health Network has resulted in an additional 97

workshops being conducted in local communities. These include Confidence Building, Foodwise, Practice

Health Walks and Routes to Wellness. 546 patients attended these workshops

Social Prescribing is now more widely recognised by primary care as an additional or alternative method

for supporting a patient’s wellbeing. At the start of the initiative 6 practices in Cardiff & The Vale opted to

utilise the service. By January 2018 17 practices were actively engaged in referring their patients

In October 2017 one primary care locality directly invested funds from their clinical pot to enable the

Wellbeing team to expand into their area to support their patients

The average associated cost for each patient referred is circ £154.50

Highlights of feedback from Patient Satisfaction Survey

“I have reduced my alcohol consumption and number of sleeping tablets. I feel more in

control and happier”

“I really appreciate all the help and it was good to focus on the good things in my life not

just my illnesses”

“I feel a lot more positive and the advice has proved really valuable”

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“Helped motivate me to become healthier and improve my fitness”

“The service was excellent, I am grateful my GP referred me and the appointment was very

quick”

Wellbeing 4U Scheme Referral Numbers

Medical Practices Referrals

Central Vale Cluster

Participating Surgeries: - Highlight Park Practice, Court Rd Surgery,

Waterfront Medical Centre, West Quay Medical Centre

325

City & South Cluster

Participating Surgeries: -Grange Medical Centre, Saltmeade Centre,

Claire Road Centre, Corporation Road Centre, Cardiff Bay Centre, Grange

Health Centre

580

South West Cluster

Participating Surgeries: - Ely Bridge Surgery, Woodlands Centre,

Westway’s Centre, Caerau Lane Surgery, Lansdowne Surgery and Fairwater

Health Centres i

592

South East Cluster ii

Participating Surgeries: - Cloughmore Surgery, Albany Surgery, Roathwell,

Clifton, City & Cathays

252

Note: Not all practices named above joined the initiative at the beginning. Practices came on board over

the 2-year period.

Total number of referrals made was 1749 and the average ‘did not show’ rate per quarter was 27%. This is

comparable with other Social Prescribing Programs and in line with expectations.

Referral Community % of referrals made by group

GP’s 88.9%

Other practice staff 4%

Self-referral by patient staff 6.5%

Other community organisation 0.5%

Reason for referral % of total referrals

Frequent attenders 1.04%

Harmful behaviours 6.69%

Immunisation advise 5.02%

Mental Wellbeing 28.69%

Physical Wellbeing 9.44%

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Social Wellbeing 11.79%

Screening advise 3.59%

Overall Wellbeing iii 33.74%

Targeted Health Activities in the Community

Health & Wellbeing Workshops 97

Immunisation & Screening activity 443

Health Events ( MECC’s) 10 153

Note: MECC (Making Every Contact Count) approach aims to empower staff working particularly in health

services, but also partner organisations, to recognise the role they have in promoting healthy lifestyles,

supporting behaviour change and contributing to reducing the risk of chronic disease.

10www.cardiffandvaleuhb.wales.nhs.uk/making-every-contact-count

i Fairwater Health Centres Data is captured in South West Cluster for ease as it was the only practice in the North that was participating so the WB4U team worked across both clusters.

ii South East Cluster participated from October 2017 for 6 months due to funding requirements in primary care needs elsewhere in the cluster iiiOverall Wellbeing was a category used from April 2016-Oct 2017. Thereafter it was broken down into several Wellbeing area’s – social, mental & physical

Age data of referrals

12%

21.

2%

18.

8%

2

1

%

13.

8%

12.4%

17-25 26-35 36-45 46-55 56-65 66 plus

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Practice Satisfaction Survey

A survey was recently conducted amongst the participating general practices. All staff were asked

to respond (clinical and non-clinical). Below are the questions, results and comments offered

Question Yes/No/Other Result

(Q1) Do you feel the WB4U social

prescribing service is an added value to your

practice & patients?

Yes 100% of respondents declared Yes

(Q2) Do you find it useful to have an

additional referral pathway (WB4U SP)for

your patients social, welfare and wellbeing

needs that are not medical?

Yes 100% of respondents declared Yes

(Q3) Does having WB4U SP help you as a

health professional feel you have

alternatives to offer you patients?

Yes 100% of respondents declared Yes

(Q4) If WB4U SP were withdrawn would it

have a negative impact on your practice and

patients?

Yes 100% of respondents declared Yes

(Q5) As a health professional have you

benefited (saved time, decrease in patient

appointments, increase in patient

wellbeing) from using the WB4U SP service?

Yes 100% of respondents declared Yes

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Comments

Improved awareness of social prescribing and what the wide range of services can offer via Wellbeing 4U. I

have seen a reduction in presentation and also medication in a number of our patients, return to work and

improved self-esteem leading to re engagement with society in some of our patients.

Dr Shiladitya Sinha Practice: Saltmead Medical Centre

‘It’s difficult to quantify exact benefits but generally patients speak highly of the service. It is useful to have

another service to refer patients with social problems, as this is a large part of GP time and also an area

which we are not very well equipped to deal with’

Sophie Marett – Saltmead Medical Practice

‘Excellent service, thank you’

J Hyam Grange Medical Practice

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Community Services

Operating in the current economic climate involves navigating services that have both available funding

and capacity. There are many excellent examples of voluntary and statutory services but Social Prescribing

referrals are made without any funding attached which can sometimes cause delays and conflict for

overstretched community services. Building community relationships and goodwill is therefore a key part

of the coordinator role.

Sample list of services referred into April 2016 – March 2018 This is list is not a complete list as there are far too many to list, however, if you wish to see a full list this can be obtained through the Wellbeing team. A copy of each of the last two-year quarterly reports contain this data.

Social Welfare and Money Management Citizens Advice Bureau

Speakeasy

Oasis Centre

The Local Authority Hubs advice sessions

Housing Associations’ Money Advice teams

Community Activity and Social Groups Age Connect

FAN

Community Gateway

Cryws Road Mosque

Pentrebane Community Centre

50+ Conway Group

Lansdowne Community Gardening project

Women Connect First

Coffee & Co

Make & Meet

Communities 1st Activties

Health and Wellbeing Routes to Wellness

Exercise Referral Scheme

Mind Cymru

Local Authority Leisure Centre Classes

Change, Grow, Live

Slimming World

Cardiff Park Walks

Age Connect

Wellbeing 4U Community Practice Walk Group

Change4life

Grange Pavillion Group

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EPP Cymru

Care and Repair

Services for those identified with emotional, mental health needs and

substance misuse

Smile – Journey’s peer support

CVAMH

Inroads

Women’s Aid

New Pathways

BAWSA

EPP Cymru

EDAS

Taith

Llamau

Mind

Alzheimer’s Society

The Mentor Ring

Action for Living

Peer Mentoring Service

Pave the Way

There were also many smaller local community group referrals made

Highlights of feedback from clinical referrers

Practice Manager - Grange Medical Practice

“The GP partners are thrilled with the results so far and have pipelines of work

available to the team that will help make a significant difference to the quality

of life for those patients in the most economically and socially deprived ward

of Cardiff.”

GP - Fairwater Health Centre

“I have referred a number of patients to the Wellbeing 4U service; usually

these are patients with high levels of demand and complex psychosocial issues

impacting on their health which are a very difficult group to help. I have had

good feedback from many of these patients about the service they received.”

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GP – Lansdowne Health Practice

“Support has been provided for patients with a variety of needs including

social isolation, mental health and wellbeing, debt and benefits advice and

healthy lifestyle. This has had a positive impact on GP workload as well as

supporting patients in addressing their own health and social needs.”

GP – Corporation Road Surgery

“Wellbeing 4U support is fundamentally important; it fills a gap in supporting

mental health problems created by social-economic difficulties which cannot

be dealt with by a Counsellor or Psychiatrist.”

Case Studies

Support helped elderly patient stay independent and happier in her own home

An elderly lady living alone was referred by her GP as she had repeatedly missed her flu immunisation

appointments and there were some concerns about her mental wellbeing. On connecting with the

Wellbeing Coordinator, it was quickly established that the lady, who also had previously suffered a

collapsed lung, hip replacement and arthritis, was struggling to get out and had difficulties getting around

her own home. She had little motivation and her mood was low. Her sister, who provided some support,

was going away for an extended period of time. The coordinator took the lady to the vaccination

appointment and after completing two further face-to-face sessions, a referral to Care and Repair was

made for adaptions to her home to ease access and prevent falls. The lady was referred to a befriending

service and a link to Greenlink Community Transport Services was established to enable the patient to get

to appointments. A signpost was also made to EPP Cymru for the patient to attend a four-week course to

help her learn new techniques to manage her long term health condition and meet likeminded people. The

patient has reported a positive increase in her overall wellbeing.

Support helped patient experience hope for the future and reduce their harmful behaviours

The patient was referred to Wellbeing 4U by her GP as a result of increasing harmful behaviours (smoking

and drinking heavily) following the sudden loss of her partner. During the first session with the coordinator

the patient talked about her alcohol misuse, smoking and overuse of sleeping tablets which had also

resulted in a breakdown of her relationship with her teenage son. She had thoughts of suicide and felt

hopeless about the future. Over a period of a month, a further three sessions were held and signposts and

referrals were made to Cruse for bereavement counselling; MIND for a course on managing harmful

thoughts and support was accessed to advice on benefit entitlement. Her son was also supported; as he

enjoyed sport he was linked to a local rugby club to help him establish friends and have a place to go

outside the home. The patient was provided ongoing emotional support along with advice on reducing

smoking and drinking. Over time, the patient has reported significant reductions in both alcohol and

smoking and is no longer taking sleeping tablets and her relationship with her son has greatly improved.

Getting the right support and advice for a carer helped the whole family move forward

Having his 91-year-old mother living with him presented the patient with many issues including stress and

anxiety over her deteriorating mental health and not knowing how to access support was adding to the

worry. The gentleman was concerned his mother was demonstrating signs of dementia. The Wellbeing

Coordinator reassured the man that there was support in the community and we would support him

through the process. Over the next two sessions he was talked through the process of getting a dementia

diagnosis, signposted to Dementia UK and a local support group and given information on benefits for

carers to help understand there was financial support should he need to reduce his working hours. The

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patient felt relieved and less stressed knowing there was a support network out there should he require it

and felt more positive about the future.

Support to take ownership of his future helped patient take first steps towards employment A GP

referred the patient as he was demonstrating poor mental health, drinking heavily and was frustrated

about his future as he had failed to get support from traditional support services previously. Through

the process of MI it was discovered that the patient’s drinking had escalated after the breakdown of his

23-year marriage. He had been unemployed for six years and had spiralling debts and was now

homeless and sofa surfing. He was supported to complete his PIP and ESA applications and attended a

money advice and housing meeting with the local authority.

After discussing his skills and likes, he was referred to Communities for Work where he has since started a

fork lift truck course and computer course. He has reconnected with his family and is living with his sister

while awaiting updates on his housing options. His creditors have now been communicated with and a

debt plan has been put in place. The patient is feeling more optimistic about his future and is enjoying

learning new skills and feeling part of the community.

Regular exercise led to weight loss and enthusiasm to get fit and healthy

As a small business owner the patient worked long hours and had never found the time to look after his

health and eating habits. Over time he had put on a lot of weight and was finding it hard to even climb the

stairs without being out of breath. After a period in hospital he was referred to a Wellbeing Coordinator as

he wanted support to change his behaviours. After assessing the patient’s abilities, he was referred to the

Wellbeing 4U exercise class ‘Routes to Wellness’ which is held in the local medical practice. The patient

regularly attends and has lost four stone so far. The patient has also taken advice on healthy eating and has

reported an increase in his mental and physical wellbeing. His daily routine has become much easier and

he is feeling more confident.

Building confidence helped patient address issues and improve their mental health

Referred by his GP, the patient was struggling with mental health issues as a result of a family breakup and

reduced contact with his children. At his first consultation, the patient demonstrated high levels of anxiety

and depression and hopelessness about his future. During the subsequent sessions the patient was

referred to the Wellbeing 4U Confidence Building four-week course. This course has helped the patient

identify triggers of his anxiety and learn tools and techniques for managing it better. This has also helped

him make small behaviour changes that have instilled confidence that things can positively change. The

patient continues to work with the team to support his ongoing development and is now reviewing his diet

to help him reduce his weight and keep fit. Overall the patient is feeling more optimistic about his future

and feels in control.

Learning and Recommendations

There has been significant learning during the past two years about what works well for patients, referrers

and the services referred to.

From qualitative evidence such as case studies, patient and clinical feedback, it is clear that Social

Prescribing is highly valued. Below is a summary of key learnings and recommendations.

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Referral & engagement process

From the implementation period it became evident that the need to educate all practice staff in the

concept and impact of Social Prescribing is vital before a coordinator starts taking referrals. This improves

the level of communication between health staff, patient and SP and helps ensure appropriate referrals are

made.

It is important to attend the practice and cluster meetings to ensure SP remains high on the clinical agenda

and to encourage consistency in participation and referrals.

Setting clear expectations of what the SP Coordinator can / is able to do with a patient at the very first

consultation. Some patients are highly complex and they can take the view that the coordinator is a

‘support worker’, taking little responsibility for their participation but demanding high levels of input. With

a small team and increasing referrals it is important to establish clear boundaries and expectations i.e.

number of consultations and the level of self-engagement required from the patient. The model moved

from a ‘signposting’ intervention to a three stage approach to be able to work across the various patient

groups

Referral tool; at present the referral process is manual. This can lead to lag times in the coordinator picking

up / receiving the referral. We are continuing to investigate how the Wellbeing 4U team can either have

access to Vision / Emis so the referral forms can be housed on the GP systems and any actions can be

recorded in the patient’s records. This would save time and ensure the health practitioner has the most up

to date information on their patients’ progress.

Part of the contract KPI’s was to deliver education to specifically identified patients regarding

immunisation and screening to support the health prioritise to drive these figures up in some of the most

resistant area’s and groups. It quickly became apparent that to do this several data sharing protocols

needed to be in place and without this it was difficult to meet this requirement. However, the Wellbeing

4U team utilised its own data sharing consent to discuss these areas with those patients engaging with the

service. In future it is imperative that any targeted work is fully scoped by those commissioning, include

GDPR, to measure the requirements and impact to primary care providers.

Staffing

Initially the model was set up as a two tier approach. A Wellbeing Assistant would see all referrals at

stage one and either signpost those patients with low need and higher motivation, or pass them

through to a coordinator if the need was more complex and required some form of ongoing support.

This proved challenging for two reasons. Firstly, managing the volume at stage one with three assistants

and secondly, the patient had confided in the assistant at stage one that they were hesitant to move onto a

second person. We adapted our team so all staff were skilled to coordinator level, sharing the referrals

more equitably and more importantly building stronger relationships with patients.

Hub-working was developed in the last quarter of 2016 in response to more practices wanting to refer

patients in a cluster, as well as the need to utilise space in the surgeries effectively to see more patients

rather than travelling between surgeries.

Working with such a variety of patients and linking them to support services led to the identification, in

some clusters, of gaps in services. These gaps included no provision, waiting lists for groups and cost

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barriers, therefore we implemented practice based initiatives (Practice Walking Group, Confidence Building

Groups) that support small groups of patients across several clusters. This has led to the addition of a

Wellbeing 4U Health Coach that the team can refer their specific patients into.

Evidence 13

Warwick Edinburgh Measure of Wellbeing Scale (WEMWBS)

The use of the Warwick Edinburgh Measure of Wellbeing Scale was implemented at the beginning of this

initiative.

Although baseline scores were obtained, there has not been a significant enough number or consistency

applied to present any meaningful statistical analysis in this report. There are a number of reasons for this:

Some patients attend just one or two sessions and therefore a before and after measure is not

applicable

It is not appropriate to use in a session where people are distressed

It is often difficult to predict when and whether a final session will occur; this is driven by the patient

There were language barriers in some cases

It became apparent further into the project that this tool may not be best suited to measure success of

interventions.

13https://measure.whatworkswellbeing.org/homepage/recommended-questions Wellbeing 4U has worked on developing a more robust working practise and evaluation process based on a

three-stage plan whereby individuals are guided to identify their priorities, supported to take realistic steps

towards making changes and provided with accurate and relevant information to help them maintain these

changes long term. As part of our initial assessment we use a visual aid called the Wellbeing Wheel which

has 10 life areas (and incorporates the Five Ways to Wellbeing) and is graded 1-10 in terms of client

perception. Using MI, MECC and strength-based principles the client is supported to pinpoint their

priorities for change. Wellbeing coaches are trained to provide public health messages where relevant and

appropriate during this process (for example with regards to smoking cessation, alcohol consumption,

weight management, immunisation and screening) and the second stage of the process (which may take

multiple sessions) is to set realistic and achievable goals, taking full advantage of resources we have

developed to support the identification of strengths and values. The third stage involves providing accurate

signposting and guidance based on individual needs. We will use the four Office for National Statistics

questions on Wellbeing at our first meeting and at the final meeting as a benchmark for the success of the

intervention and to provide robust evidence that can be evaluated using comparison groups from the

annual local ONS survey findings. We also have a new demographic survey that will allow us to map

patterns and provide evidence for gaps in provision or lack of engagement in specific groups or

communities. This new process will be piloted in quarter 3 of 2018.

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Along with measuring wellbeing, developing quantitative evidence of the cost saving to primary care is

desirable. Any future funding will be reviewed and part apportioned to commission appropriate research.

Commissioner Engagement

For new services to have impact it is vital to have early support of primary care leads, third sector council,

local authority leads and public health teams to ensure that strategies evolve that cut across the varied

needs of the communities and service providers and to avoid duplication of resources and money. When a

model relies on the referrals, involvement and goodwill of clinical staff it is important that their views are

sought at the very onset of commissioning to ensure buy-in and success.

Summary

It is clear that Social Prescribing is becoming more widely recognised as a key intervention in helping

people to achieve happy and healthy lives. SP is able to provide a holistic intervention and fulfils a gap

which cannot be met by general practice alone, for understandable reasons. The work of the Wellbeing

Team has shown qualitative benefits to patients, GP surgeries and the local community, as demonstrated

in the case studies and feedback.

The model of delivery has evolved during the first two years as we have overcome challenges and looked to

see how we can reach as many people as possible. The service has adapted flexibly to meet the needs of

GPs, patients and the wider community. While this is what is needed, it has made it difficult to provide

quantitative data in relation to outcomes. This is something we want to explore as we work through into

our third year of delivery.

As the benefits of this service are becoming better known within the health community the demand for our

service has grown, with more GPs asking us to provide the service in their surgeries. However, while it is

positive that the benefits of SP are spreading, we are a small team and unable to work in every GP surgery

at the current time, mainly because we do not want to dilute the impact of what we can achieve.

The long term funding is also something that causes concerns and challenges. Building relationships with

GPs, staff in primary care settings, patients and the community takes time and understandably some

people can be wary of short-term funded projects, as whilst they provide an immediate benefit when they

are operational, they leave gaps in provision when they end. Although it is recognised that the long term

benefits for the individual, communities and health practitioners of SP may not be known for a number of

years, there needs to be a strategic commitment to invest in the model to ensure that SP stands a real

chance of becoming part of the everyday health provision and choice.

We recognise that there is scope and potential to develop this service further and help people to achieve

even better outcomes, having a positive impact on communities and reducing the pressure on primary

care.

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Case Study

Stuart was referred by his GP for depression, substance misuse, homelessness and no social connections in Cardiff

Through Motivational Interviewing,we identified and supported goals focused on what mattered and agreed appropriate signposting.

With our support, Stuart has engaged with Solas Cymru for alcohol misuse, New Pathways for historical abuse support, LA Hub for support with ESA application, Local food bank to support nutrition, Grant support for household items when moving into independent flat and Volunteering with local charity and church.

Where is Stuart now?

Stuart has been substance free for over a year, out of supported housing and is living in his own home. Stuart works two days a week in a charity shop and also volunteers every weekend at the church soup kitchen and he is no longer taking anti-depressants.

Next steps are to engage with a training provider to look at paid work options.

Cost savings £9,076 per year saved for statutory services

and £9,186 additional potential savings when he enters

work.

What next?

Wellbeing 4U was successful in its bid to continue managing the service and the new contract award runs

from April 2018 to March 2020.

Priority Actions for 2018/2020

Continue to review additional review streams to enable the service to grow and offer equity and equality

of access across the clusters in Cardiff and The Vale of Glamorgan

Pilot a more robust engagement and wellbeing evaluation tool in quarter three 2018

Implement the Healthful Network program across all participating clusters

Implement a larger pilot study, in one cluster, to work with a specific cohort of patients (pre-type 2

diabetic ‘at risk) to demonstrate what qualitative and quantitative evidence there is for a weight

management program coupled with behaviour change modules in reducing patients risk

Continued development of the IT recording management tool (Wellog) and review of digital referral

platforms to aid patient pathways

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Utilise the Healthful Network Quarterly gatherings to identify community champions

Continue to work in collaboration with SW Cluster to progress the development of the SW Social

Prescribing Network ( Known as ‘The Tribe’).